title: Cost effectiveness of intraoperative pathology examination during diagnostic hemithyroidectomy for unilateral follicular thyroid neoplasms.
abstract: BACKGROUND
  The use of intraoperative pathology examination (IPE) during diagnostic hemithyroidectomy for a follicular neoplasm is controversial. Although this service rarely alters intraoperative decision making, it does provide patients with the possibility of avoiding reoperation for completion thyroidectomy if malignancy is detected. We hypothesized diagnostic hemithyroidectomy with IPE for a unilateral follicular thyroid neoplasm diagnosed on fine-needle aspiration is not cost effective compared with diagnostic hemithyroidectomy alone.
  
  
  METHODS
  Cost-effectiveness analysis with a Markov decision model was performed comparing diagnostic hemithyroidectomy without IPE, diagnostic hemithyroidectomy with IPE, and total thyroidectomy. Treatment outcomes and their probabilities were identified based on literature review. Costs were estimated using data from Medicare, the US Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Sensitivity analysis and a 1,000-iteration Monte Carlo simulation were used to examine the uncertainty of cost, probability, and utility estimates in the model.
  
  
  RESULTS
  Diagnostic hemithyroidectomy without IPE had an expected cost of US$7,665 and an effectiveness of 23.95 quality-adjusted life years and dominated both the IPE and total thyroidectomy strategies. Intraoperative pathology examination became cost effective during one-way sensitivity analysis if the sensitivity of IPE increased from 14.3% to 34.4%, the specificity increased from 98.6% to 99.8%, or the pretest probability of malignancy increased from 25% to 43%. Monte Carlo simulation demonstrated that the intraoperative pathology strategy was not cost effective in 92.7% of iterations.
  
  
  CONCLUSIONS
  Intraoperative pathology examination is not cost effective in the diagnosis of follicular thyroid neoplasms during diagnostic hemithyroidectomy. Improvements in both the sensitivity and specificity of this service would be needed to justify its use.
authors.affiliation: Department of Surgery, Section of Endocrine Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors.forename: Kyle
authors.initials: K
authors.lastname: Zanocco
authors.forename: Michael
authors.initials: M
authors.lastname: Heller
authors.forename: Dina
authors.initials: D
authors.lastname: Elaraj
authors.forename: Cord
authors.initials: C
authors.lastname: Sturgeon
mesh_terms: D018263:Adenocarcinoma, Follicular / Q000191:economics / Q000473:pathology* / Q000601:surgery; D044963:Biopsy, Fine-Needle / Q000191:economics; D003362:Cost-Benefit Analysis; D005629:Frozen Sections / Q000191:economics; D006801:Humans; D007430:Intraoperative Care / Q000191:economics*; D008390:Markov Chains; D013964:Thyroid Neoplasms / Q000191:economics / Q000473:pathology* / Q000601:surgery; D013965:Thyroidectomy / Q000191:economics*
keywords: FNA; FS; IPE; QALY; RLN; fine-needle aspiration; frozen section; intraoperative pathology examination; quality-adjusted life year; recurrent laryngeal nerve